2. Disclosures that do not require a parent or student’s permission
• Child Abuse: If, in our professional capacity, it comes to our attention that a child is abused/maltreated, we
must report such abuse/maltreatment to Child Protective Services.
• Emergency Situations: We may use or disclose information about a student if we are unable to obtain
parental consent yet emergency treatment is needed. If this happens, we will try to obtain parental consent
as soon as we reasonably can after providing or arranging for treatment.
• To Avoid Harm: We may disclose information about a student to protect the student or others from a
serious threat of harm by the student.
• National Security: We may be required, by federal law, to disclose information about a student to federal
officials for intelligence and national security activities.
• Release of Information to Parents or Guardians: While your child is a minor, you have right to discuss
your child’s counseling with her/his counselor. Once a student reaches the age of 18, he or she will be asked
to complete a new consent as a legal adult. After your child turns 18, you can ask her/him give the counselor
written permission to allow two-way communication between yourself and the counselor. If your child does
not sign such
a release at that time, you can communicate information to the counselor, but the counselor
will not be able to confirm whether or not your child is continuing in counseling or talk to you about your
child’s counseling experience.
• Lawsuits and Disputes: We may disclose information about a student if we are ordered to do so by a court
or administrative tribunal.
III. THE STUDENT’S RESPONSIBILITIES
Active participation in the counseling process is necessary for progress to be
made. It is important
that a student notifies the counselor if problems worsen.
It is the student’s responsibility to keep scheduled appointments, unless rescheduled or canceled at
least 24 hours in advance.
The Counseling Center staff is interested in any positive or negative feedback, students may have
regarding the services received. We periodically ask students to complete an anonymous evaluation
asking for feedback about our services. If for any reason a student is not satisfied with the
counseling process, we encourage that person to discuss this first
with his or her counselor. If
concerns are not resolved to a student’s satisfaction, the student may request an appointment with
the Clinical Director of Mental Health Services to discuss possible reassignment or
I am the parent or legal guardian of ________________________________.
nt’s Name (Print)
I have received a copy of the Fredonia Counseling Centers Parental Consent for Treatment form. I have read
and fully understand the information contained in this form. I hereby give my permission to the professional staff
the Fredonia Counseling Center to engage in counseling services with my minor child.
Student’s Name (Print)
Student’s Date of Birth
Name of Parent/Legal Guardian (Print)
Signature of Parent/Legal Guardian
This form will be faxed,
emailed to a parent.
Please return the
form to the Fredonia Counseling
Center to the fax number
address on this
form or in an email
elect to verify parental consent upon receiving the
click to sign
click to edit